The value of Faecal Occult Blood Test in patients infected with intestinal parasites

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1 The value of Faecal Occult Blood Test in patients infected with intestinal parasites Manar Ezzelarab Ramadan 1, Mohamed Ezz Elarab Ramadan 2, Mervat Shafik Mohamed Yousef 3 1 Parasitology and immunology Fellow, Parasitology Department National Hepatology and Tropical Medicine Research Institute, Egypt manarezz98@yahoo.com Gasteronterology and Hepatology Fellow, HepatologyDepartment Ahmed Maher Teaching Hospital, Egypt. ezzm3@yahoo.com Professor of Chemical and clinical pathology, Chemical and clinical pathology department ABSTRACT Ain Shams University, Egypt. shafikm3@yahoo.com Infections due to intestinal parasites are among the most prevalent infections in humans in developing countries. Faecal occult blood refers to blood in the faeces that is not visible to the naked eye and FOBT, as the name implies, is aimed to detect subtle blood loss in the gastrointestinal tract from the mouth to the colon.this study aimed to prove if there is a relation between FOB and intestinal parasites. Stool samples of 450 patients attending different out patient clinics in Ahmed Maher Teaching hospital, Egypt. Direct smear and The spontaneous faecal sedimentation method, Hoffman, Pons and Janer (HPJ) technique (HPJ) technique were used for the detection of the intestinal parasites. A commercially available immunological FOBT kit was used to detect FOB. The result showed that ( 47.1% ) of studied cases were infected by parasitic infection, 27(43.5)% of them were positive for FOB. Parasites detected were Schistosoma mansoni, Entamoeba histolytica, Giardia lamblia, Hymenolpis nana, Ascaris lumbricoides, Anckylostoma duodenal, Entrobius vermicularis, Trichuris trichuria and strongloides stercoralis. 90 (42.8%) of the studied male cases and 122(50.8%) of female cases were positive for FOBT. Patients older than 30 years old, 48.9% of them were positive for FOBT. We concluded that this study demonstrated a slightly high Page 120 ISSN

2 prevalence positive FOBT, no association between intestinal parasitic infection or sex and positive FOBT,although a significant relation was present between age and positive FOBT. We recommend that FOBT, due to its low-cost and ease of use, we advocate for the immediate integration of FOBT as a tool in as routine tests in clinics and hospitals especially for old aged patients,further studies should be done for detection of correlation between other intestinal parasitic infection and FOB. Keywords: Intestinal parasites,fobt (Faecal Occult Blood ), HPJ (Hoffman, Pons and Janer ) technique. Page 121 ISSN

3 The value of Faecal Occult Blood Test in patients infected with intestinal parasites Manar Ezzelarab Ramadan 1, Mohamed Ezz Elarab Ramadan 2, Mervat Shafik Mohamed Yousef 3 1 Parasitology and immunology Fellow, Parasitology Department National Hepatology and Tropical Medicine Research Institute, Egypt manarezz98@yahoo.com Gasteronterology and Hepatology Fellow, HepatologyDepartment Ahmed Maher Teaching Hospital, Egypt. ezzm3@yahoo.com Professor of Chemical and clinical pathology, Chemical and clinical pathology department INTRODUCTION Ain Shams University, Egypt. shafikm3@yahoo.com The mortality and health problems due to parasitic diseases cause retard social and economic development in low-income countries (CDC,1997).About one third of the world (more than two billion people) is infected with intestinal parasites (Chan,1997).About 39 million disability adjusted life years (DALYs) are attributed to intestinal parasitic infection (IPI) and thus represents a substantial economic burden due to these infections(who,2008). The burden due to schistosomiasis (mainly Schistosoma mansoni S. haematobium and S. japonicum) is estimated at 4.5 million DALYs (WHO,2002& Hotez etal.,2006).amoebiasis due to infections with the intestinal protozoon Entamoeba histolytica results in 40, ,000 deaths each year(stanley,2003), and giardiasis due to Giardia intestinalis might affect 200 million people per annum (Minenoa and Avery,2003) Symptoms of parasitic infection include abdominal pain, dizziness, fever, nausea, diarrhoea, hair loss, etc... (Raj, 1999). Faecal occult blood (FOB),(Mitchell et al.,2004), which refers to cryptic blood in faeces, has been used for a number of years as a marker of intestinal pathologic changes, particularly in association with colorectal cancer. A number of point-of-care tests have been developed (Hewitson et al., 2008, Wu et al., 2009, Jenkinson &Steele 2010) and as such, they Page 122 ISSN

4 are simple to use and provide a result in minutes. There are various causes of positive FOB including infection with some intestinal parasites (Beg et al., 2002). FOB has also been used for identifying blood loss in parasitic enteric infections with hookworm, Trichuris trichiura or Entamoeba histolytica (Stoltzfus et al.,1996, Raj, 1999, Okamoto et al., 2005, Wanachiwanawin et al.,2005). The objective of this study was to prove if there is a relationship between the results of FOB test and intestinal parasitic infection. METHODS 1. Sample Collection and Processing This study was carried out on 450 patients attending the outpatient clinics of Ahmed Maher Teaching hospital, Egypt.Three specimen containers were given to each subject for giving stool samples for three consecutive days and the procedure for introduction of stool specimens into the containers was carefully explained to them.stool were labelled before processing. For each stool sample, two slides were examined for the detection of parasites by two investigators using optical microscopy (Nikon, Japan) at 100X and 400X magnifications. Most Samples were processed immediately and examined, others were stored at 4ºC without a preservative solution according to the protocol described by Oliveira et al.,(2002). 2. Parasitological examination. 2.1 Direct smear: A portion each of the stool samples was processed with a direct microscopic technique to detect cysts, trophozoites, eggs and larva of intestinal parasites immediately according to (WHO,1991). 2.2 The spontaneous faecal sedimentation method Hoffman,Pons and Janer (HPJ)technique(Hoffman et al., 1934).In this method, faecal samples are diluted in water and filtered through a gauze strip into a conical sedimentation glass. The HPJ method was used to detect the presence of helminth eggs and larvae and protozoa cysts. This technique is widely used in epidemiological studies, due to its low cost. 3-Simple chromatographic test was employed for FOB detection (Mission TestH, Acon Laboratories, San Diego, CA), following the manufacturer s instruction, a small amount of feces was homogenised in a liquid buffer after collection. Two drops of stool suspension Page 123 ISSN

5 were applied to a test cassette and results were visually read after five minutes and categorized as negative (-), trace (+/-) and positive (+). 4-Statistical Analysis. Data analysis was performed using SPSS statistic PackageV17.0. The Chi square test was used.a P-value level of significance was RESULTS Table (1): FOB in relation to parasitic and non parasitic infection Parasitic infection Negative parasitic infection n= 388 (86.3%) Positive parasitic infection n= 62 (13.7%) +ve FOB 183(47.2%) 27(43.5)% ve FOB 205(52.8%) 35(56.5%) P value From total 450 patients,62(13.75) patients are infected with intestinal parasitic infection,27 of them (43.5%) were positive for FOBT and it was found that no significant relationship between patients infected with intestinal infection and others non infected (p value was >0.05=0.74 Table (2): Results of FOBT in relation to their sexes in the studied cases. No.of +ve cases for FOB -ve cases for FOB P value cases Male (42.8%) 120(57.2 %) P value 0.18 Female (50.8) 118(49.2%) Total (47.1%) 238(52.9) The studied cases were 450,210 of them males, and 240 were females. There were 90 cases (42.8%) positive for FOBT and 122 of females (50.8%) were positive for FOBT.No significant relationship was present as regard the positivity of FOBT and sex. Page 124 ISSN

6 Table(3)Results of FOB according to age in the studied cases. AGE <30 n =16 31>60 n=434 +vefob % 48.9% 212 _ve FOB % 51.1% 232 P value =0.04 Table 3 :showed that the number of patients < 30 years old age were (16),two of them were positive for FOBT and patients who were from 31 to >60 years were( 434), (48.9%) of them were positive for FOBT.A significant relationship was detected as p value was Table (4): Prevalence of parasitic infection detected in the studied cases. Parasite (n=62) +ve FOB _ve FOB Schistosoma mansoni (n=3) 1 2 Entamoeba histolytica (n=16) 8 8 Giardia lamblia (n=2) 0 2 Hymenolpis nana (n=5) 3 2 Ascaris lumbricoides (n=18) 6 12 Anckylostoma duodenale (n=9) 3 6 Entrobius vermicularis ( n=3) 0 3 Trichuris trichuria (n=5) 5 0 Strongyloides stercolaris (n=1) 1 0 Total According to Table (4) :The detected parasites in the study were three cases Schistosoma mansoni, one of them were positive for FOBT. Entamoeba histolytica were 8 of them were positive for FOBT. Two Giardia lamblia were detected and both were positive for FOBT.Of the five cases of detected Hymenolpis nana, three of them were positive for FOBT. Nine patients were infected with Anckylostoma duodenale,three of them were positive for FOBT, all detected cases of Entrobius vermicularis were negative for FOBT. Although all detected cases of Trichuris trichuria and Strongyloides stercolaris were positive for FOBT. Page 125 ISSN

7 DISCUSSION Several coprologic techniques have been utilised in parasitic disease diagnostic tests; in this research work we used direct smear and the HPJ method to detect intestinal parasitic infection in stool samples. HPJ technique is widely used in epidemiological studies, due to its low cost. It had a higher positivity rate for hookworm (Cerqueira et al.,2007).this method had high positivity rates compared to other methods for the detection of parasite larvae (De Carvalho et al.,2012). Faecal occult blood test (FOBT) is used in the screening and monitoring of patients with gastrointestinal disorders (Gisbert etal.,1997&jorgensen etal.,2002). Annual or biennial faecal occult screening has been shown to significantly reduce the incidence of colorectal cancer (Mandel et al.,2000& Towler etal.,2000). The process of FOBT in the past has been time consuming and aesthetically offensive to laboratory staff (Gregor, 1997& Hewitson et al.,2011). The advantages of the FOB immunochemical test are their relatively low cost, easy to use with very little technical expertise required and not need dietary or medical restriction as guaiac-based faecal occult blood (FOB) tests (Beg et al.,2002). In addition immunological faecal occult blood tests had proven to be more sensitive than other Guaiac-based fecal occult blood (FOB) tests (Guittet et al.,2009&.rex et al.,2009). (13.7%) of the examined patients were infected with intestinal parasitic infection (Table 1),it was low percentage compared with waked,(2010) and Nmorsi et al.,(2009) as they reported(47.01% ) and(94.3%) respectively.this low percentage also detected in an earlier studies done by Omorodion et al.,(2012) and Ugwuoke et al.,(2013) as they documented an overall prevalence of 12.3% and 13% respectively. Low prevalence of intestinal parasitic infection in this study may be due to the method of selection of cases to be included, as we select them randomly from who attending the outpatient clinics in the hospital for different causes. During this study several pathogenic intestinal parasites were detected.there was no significant difference in FOB positivity between infected and non infected cases, this was agreed by some authors (Wakid, 2010& Ugwuoke et al., 2013). The common parasites which were detected and can cause dysentery or blood loss were Trichuris trichiura, hookworms, Schistosoma mansoni, and E. histolytica in agree with other studies carried out by Wakid,(2010)& Ugwuoke et al.,(2013).50% of E. histolytica cases Page 126 ISSN

8 were positive for FOBT as reported by Ugwuoke et al.,(2013).in an earlier study Okamoto et al.,(2005) reported four asymptomatic cases with positive FOB test and amoebic colitis due to E. histolytica. We observed that all detected cases for Entrobius vermicularis and Giardia lamblia were negative for FOBT,as regard Entrobius vemicularis these results agreed with Wakid,(2010) although in a previous study done by Lee et al.,(2002) E. vermicularis gave positive FOBT but in a case with colon carcinoma. In the current study,all the Trichuris trichuria cases were positive for FOBT,although in other studies illustrated that occult blood is not correlated with T. trichiura infection, unless there is a Trichuris dysentery syndrome (TDS) ( Lee, et al.,2002, Wanachiwanawin et al.,2005, Khuroo et al.,2010). In Table (1);The positive rate for occult blood was (43.5%) in patients infected by intestinal parasitic infection and( 47.2%) in non infected ones.no significant relation was found and this was reported also by others (Wakid,2010 & Ugwuoke et al.,2013). In Table (2) the overall prevalence positive FOBT in the studied 450 cases were 212 cases(47.1%) which coincided with an earlier study carried out by Ugwuoke et al.,(2013) that detected(46.2%)of cases were positive FOBT, in contrast with other research (Wakid,2010) that reported (22.43%) of parasitic infected cases and (25.91%) of non infected were positive for FOBT. There were No significant relation between the positivity of FOBT and sex of studied cases(table 2 and 3), although it was found a positive relation between age of patients and the FOBT(P value =0.04) as patients >30 years old the FOBT was 12.5% and 48.9% in patients<31 years old,this coincided with Ugwuoke et al.,(2013) and the United states preventive services Task force (2008 ) which recommended FOBT annually for the purpose of colon cancer screening for all persons at average risk who are older than 50 years. In conclusion: This study demonstrated a slightly high prevalence positive FOBT and and age is a significant factor for positive FOBT, whereas, sex, parasitic infection do not have a significant correlation to positive FOBT. We recommend that FOBT, due to its low-cost and ease of use, we advocate for the immediate integration of FOBT as a tool in as routine tests in clinics and hospitals especially Page 127 ISSN

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